RASingh MD FRCPC AGAF Clinical Assistant Professor Division of Gastroenterology UBC Disclosures Speaker Honorarium Takeda Abbvie Janssen ID: 917176
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Endoscopic Ultrasound Primer for Endoscopy Nurses
R.A.Singh MD FRCPC AGAFClinical Assistant Professor. Division of Gastroenterology, UBC
Slide2Disclosures
Speaker Honorarium: Takeda Abbvie Janssen
Pentax Clinical Research Takeda Gilead
Celgene
Janssen
Slide3Disclosures
Grants from Canadian Association of Gastroenterology, Royal College of Physician and Surgeons and Pentax for EUS training
Slide4AgendaBasics of EUS Diagnostic Uses of EUS
Therapeutic Uses of EUSPractical Nursing AdviceQuestions
Slide5“ Polar bear in a snow storm”
Slide6BasicsUltrasound image produced by US waves which are reflected back to the transducer as echoes
Reflection occurs due to acoustic impedenceA large difference of acoustic impedence between two tissues leads to greater reflection and poor transmission
Slide7Ultrasound Mechanics
Slide8U/S Mechanics
Slide9BasicsEchoendoscope is an endoscope with an ultrasound transducer at the tip
Radial or linear ultrasound devices availableStandard EUS transducers operate from 7.5-12 MHzHigher the frequency,lower the penetrationLinear array scopes allow FNA by real time visualization of the biopsy needle
Slide10Slide11Slide12BasicsAcoustic coupling is achieved by a water filled balloon at the tip of the echoendoscope
EUS poor at delineating air filled structures or bone ( eg anterior mediastinum)Artifacts occur as in abdominal US
Slide13EUS Imaging
Anechoic
Hypoechoic
Hyperechoic
Slide14BasicsStandard echoendoscopes image five layers of the gastrointestinal wall:
Superficial mucosa ( hyperechoic) Deep mucosa ( hypoechoic) Submucosa ( hyperechoic) Muscularis propria ( hypoechoic)
Serosa (hyperechoic)
Slide15Slide16Slide17Slide18Why do we need EUS?: DiagnosticsImproved diagnostic accuracy in staging a variety of
tumoursEsophageal, gastric, pancreatic/biliary, rectal and NSCLCBenign lesions such as sub-epithelial lesions, chronic pancreatitis and CBD stones best evaluated by EUSTissue acquisition
Slide19Why do we need EUS?: TherapeuticsCeliac Plexus Blockade or
NeurolysisPseudocyst or Necrosis DrainageBiliary AccessFuture needs include local chemotherapy and RFA (radiofrequency ablation)
Slide20Basics: Tumor StagingTNM classification is used to stage tumors with EUS:
T1 Extension into mucosa/submucosaT2 Extension into but not beyond layer 4T3 Spread beyond layer 4 but not surrounding structuresT4 Invasion of surrounding structures or vesselsNodal staging are specific to type of tumors
Slide21Esophageal T1 Lesion
Slide22Esophageal T2 Lesion
Slide23Esophageal T3 Lesion
Slide24Esophageal T4 Lesion
Slide25Tumour Staging: NodesMalignant
nodes : Large (>1cm) Homogeneous Well Circumscribed
RoundIf all 4 criteria are met , the specificity is highFNA greatly increases the specificity
Slide26Malignant Lymph Nodes
Slide27Upper GI Tract: Benign Lesions
Sub-epithelial lesions: Thickened Mucosal Folds Lipomas
Carcinoid tumours Varices
Pancreatic rests
Stromal lesions
Extrinsic Compression
(
Tumours
,
Pseudocyst
, Lymph
nodes)
Slide28GIST ( Gastrointestinal Stromal Tumour)
Slide29Lipoma
Slide30Gastric/Esophageal Varices
Slide31Chronic PancreatitisMost sensitive radiographic modality for diagnosing chronic pancreatitis
Standard EUS criteria for diagnosing CPFeatures include parenchymal calcification, lobulation, dilated tortuous PD
Slide32Normal Pancreas
Slide33Chronic Pancreatitis
Slide34Slide35CholedocholithiasisMost sensitive imaging technique for detecting stones
More sensitive than MRCPSpatial resolution to 0.1mm ( sludge)Increasingly used to rule out small stones in CBD
Slide36Slide37Slide38Interventional EUSEUS guided FNA
Celiac plexus neurolysis for CP or pancreatic cancer pain. Safer approach than traditional posterior fluoroscopically directed approachOther indications include Drainage of pseudocysts, BOTOX injections for achalasia
Slide39Pancreatic Pseudocyst
Slide40Pseudocyst Drainage (Endoscopic)
Slide41Pseudocyst (Endoscopic
Drainage)
Slide42Complications of EUSOxygen desaturation Cardiac arrythmias
PerforationBleeding ( FNA)Pancreatitis ( FNA)Infection ( Local or Systemic)
Slide43Antibiotic ProphylaxisCyst Aspiration
Rectal Lesion PunctureRadial EUS exam is a low risk procedureEUS/FNA should be considered a high risk procedure based on ASGE endocarditis guidelines
Slide44SummaryEUS allows for accurate diagnosis of submucosal lesions
Greater accuracy in staging esophageal,gastric, pancreatic/ampullary and rectal carcinomaNon invasive diagnostic modality for choledocholithiasis and chronic pancreatitisEUS guide FNA allows for tissue samplingTherapeutic EUS continues to evolve
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